Scary Nuts

This week's guest columnists are Drs. Crystal Davis and Danielle Fuselier, Family Practice residents at the University Hospital and Clinics here in Lafayette. She was hungry after softball practice, and took the snack bar her friend offered.  It looked like a bar she had eaten before, so she didn't think twice.  A few minutes later, though, her throat began to feel scratchy and tight.  She got scared and called her father.  When he arrived, he saw she was pale, had a swollen face, and was breathing hard.  He gave her benadryl and called 911.  Later, the girl told us that when she looked at the snack bar package again, she saw it contained cashews.  She had an allergy to tree nuts. Severe allergic reactions can be very frightening for parents, and kids!  Everyone knows a horror story of allergies that end tragically.  Knowing the proper steps to take can save your child's life.  First, its important to identify the symptoms.  These include hives, itching, and flushing or pallor.  More severe symptoms include swelling of the lips and tongue, shortness of breath, wheezing, vomiting, and worsening lethargy. We call severe allergic reactions anaphylaxis- when the allergy affects two or more organ systems (cardiovascular system, respiratory system, skin, GI tract, etc).  Anaphylaxis can be deadly and requires quick action.  If your child has an epipen, use it!  Then call 911.  Studies show that many parents, and even doctors, don't give epinephrine often enough.  Don't be afraid to use it- it doesn't hurt kids to give (except for the shot sting itself), and can be lifesaving.  There are videos and dummy epipens for training, so parents and patients can practice for when it's needed. Your job's not over yet.  Take your child to the ER for further evaluation.  Best to call 911- paramedics carry epinephrine, steroids, benadryl, and other important anti-allergy medicines. Then at the hospital, your child will be observed in the ER and maybe admitted overnight.  Even after initial treatment, the body continues to release inflammatory cells and chemicals to attack the substance it recognizes as foreign.  Thus kids need monitoring and may require further medication. Our girl above, who had nut allergies and ate a cashew-containing snack bar, had low blood pressure, shortness of breath, and was lethargic and pale when the paramedics arrived.  They gave her an epinephrine shot, steroids, and IV fluids.  She still looked sick when the medics brought her in- pale and fatigued.  But she gave us a weak smile and insisted she felt better!  We admitted her to the ICU, and she recovered. When kids have severe allergic reactions, or lesser but still bothersome symptoms, it's important to find the culprit.  There's no single way to identify allergens.  Some types are best identified with skin tests, like inhaled allergens.  Blood tests are better to identify food allergies, or causes of eczema. When we say "skin tests," there's different kinds of that.  One is the prick test, where drops of fluid with allergens are put on the back, and then pricked into the skin with a  needle.  If the child is allergic, the skin swells and reddens around the prick, like a mosquito bite.  Up to 40 different allergens can be tested at once this way, depending on the allergist's suspicions, the size of the child's back, and what the kid will tolerate! Other skin tests are "intradermal," where allergen is injected within layers of the skin.  In cases of possible anaphylaxis, like our girl with the tree nut allergy, "challenge" allergy testing like this may not be safe- no one wants anaphylaxis in the office!  Blood testing is safer. The point of allergy testing is to find out what to avoid.- bee stings, spring pollen, kiwi.  Avoidance can be used as as an allergy test itself, particularly for foods.  Say a kid has a chronic allergy like eczema.  You start the "elimination diet," where you subtract suspected foods from the child's diet, one food per week.  If in one of those weeks the eczema suddenly improves- voila, you have the culprit! Testing can help you choose appropriate treatment: avoidance, medicines for when your kid can't avoid the air he breathes, allergy shots, or epipens.  For the potentially severe reactions, as we said above, don't be afraid to use that epipen!  It could save a life gone nuts.